040902891
CITY OF CUPERTIiVO,777777:1777777777=-u
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BUILDING DIVISION PERMIT
-_.
,kWWkACTORjNFORMATION
BUILDING ADDRESS:
PERMIT 14 0 9 02 8 9
OWNER'S NAME:
PERMIT ISSUE DATE
.E:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 t 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm Nat I am Hummel el under provision of Chapter 9 (commencing
p
with Scclion 10(10) of Division 3 of Ne Business and Professions Code, and my license is
Li�full urocl End of [t Lt«
TI -UNMANNED TEL.COMMUN. FACILITY
Dam �9-Oa�Camra<mr ^"
CONTRACTOR: STC NETCOM
ARCHITECTS DEC R TION
1 understand my plans shall W used az public ¢cords
Licensed Profcasional
OWNER -BUILDER DECLARATION
I hereby mErm Nm I am exempt from the Contractor's License Law for the
following mason. (Section 1031.5, Business and Professions Code: Any city or county
which requires a Permit to construct, alter. improve, demolish. or repair any someone
priorto its issuance, alsu requires NL applicant for such Permit to file a signed statement
he is licensed to Ne of Ne Connectors Liocnsc Law (Chapter 9
Sq. Ft. Floor Area
Va�t3�ag�00
that pursuant provisions
f�
(commencing with Section 7080) of Division J of the Business and Professions Come) or
q ��
Nit he is exempt demfnm and the basis for de allegcA exemption. Any violation of
/ab. ^
APN Number
Occupancy Type
Section 7031.5 by Any applicant for a permit subjecs Ne applicant to a civil penalty of
not mom than tae namre(sego).
34263001.00
`"e� 1
As or or my employees with wagesaz their sole compensation,
I,awner of the popery,
"+up '// q
Requir�Insp€acrion� � a
will do the work. and Nuwmum is not intended cr offered fonal. (Sect. 7044, Business
arta Profanation Code: The Contractors License Law data not Apply he an owner or
prupcnywht buildsarimprovta tkmon. and who does,uch work himselfor through his
O /
own employees, provided Nat such improvements art notinended oroRered for.iale. If,
however. the building or improvement is sold within one }ear of complaint.. the owner-
builder will have de Wrdcn of proving that k did not Wild or improve for purpose of
sale.).
I. as minor of the property, am exclusively contracting wan licensed contactors to
Gtaherson.
Businesowner
roperty
caIG
actLa 1pplyin
pp
Y
, �(/(/
anLt.d
wholon5Godes)The
an or Nd
me, lidoes oat apply la An owner of property who
d es notYd
ant
to
who Conuac
who sed p s
for such prolecs with acomm�or(s) licensed pursuant m de Convanoh
f
Lacontracts
License
Lie see law.
I in exempt undo So. , B A P C for Nis mason
Owner Dat
WORKER'S COMPENSATION DECLARATION '-
1 hemby Allan under penalty of perjury, oro of the following declarations:
have and will maintain a Certificate of Consent to self-insum for WarkcYsCom xin-
sation. az financed for by Seaton 37W of the labor Code, for the Performance of he
for which do. kernit is issued.
aworork
mi,i d by Section
Igl I have and will maintain Worker's Compensation Insurance, n iri
3 11 of the labor Code, for Ne peroomtance of on, work for which this permit is issued.
My Workers Compensation Insunn a sorties and Polk, numkram:
Cartier Policy No.: —
ERTIFICATEOFEXEMPTION FRO W RKERS'
COMPENSATION INSURANCE
(This section need not becomplLted if iW Permit is for one hundred dollars (SIM)
M kin.)
1 cent fv that in the performance of the work for which this Permit is issued, l shall not
employ anyptow any manner so as it) become subject to the Workers'Compensation
Laws of California! Date
Applicant
NOTICE TO APPLICANT: Ir. after making this Cenifeae of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you mum
forthwith comply with such provisions or this Permit OUR k deemed rooked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is 3 lending agency lot she Performance of
w s ed (See.
NL wish for which this pcmtit is issued (See. J097, Civ. C.)
Lcndci A N.
Undddoess
Agrees
�comets
1 ttnify that I have roc this application and sue that the Above information u
building I agree to comply with all city and county and cute laws
eunutivrs of this city to enter upon Ne
and hereby auNon nuains of r upon e
corned
.1mveng
pm.
above-mentioned Profane for inspection Purposes.
purpo
(WC)agree tocosts Indemnifyes hick hayiinancas ore
may in any wayseems against aid City
j way against id City
gracing expenof
� O�
2,2-
inconacquece, of Me
in cansequenec of Nc granting of this Permit.
this not.
APPLICANT
' APPLICANT UER DS D WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S E ATI
Re -roofs
Type of Roof
- 2"6
rt of aDale
HAiARDOUS MATE RIALS DISCLOSURE
HAZARDOUS
Will aous material
applicant or (mum building occupant sloe or handle m
-
As e Health and Safety
defined by the Cupertino Municipal Code. Chapter 9.12. and NHe
y
Code, Section 25532(.)+
All roofs shall be inspected prior to any roofing material being installed.
DYes ON.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment or devices which
t harardoua air contaminants az defined by the Bay Area Air Quality Management
all new materials for inspection.
"Asitia?
D Yes INu
Ihave read thehvvdnus materials Chapter 6,95 the
nus 5533Ad155under iat f
urSafety CaM,S 3and25534.1 midentand that Wilding
idws25t is notify Ie cocthebuilding
drca awr currently Wes that it u my msportsibility m notify occupant of
im, my
w cc
rtoiazaanccaricmOL:earOcetPmq.
Igna[ re of Applicant Date
1! ��,te
All roof coverings to be Class "B" or better
LOotrc, or authorised agent